Developing psychological skills has become and important part of improving the performance of various professionals including athletes, astronauts, artists, law enforcement officers, military personnel, and financial consultants.1,2 Various mainstream psychological techniques have been modified and developed with a focus on improving performance, as opposed to being employed with therapeutic intention to treat psychological pathology.3

Despite the beneficial results of training psychological skills in many other areas, little has been done to explore the possible advantages of training specific psychological skills to improve the performance of emergency medical personnel during resuscitation. Only recently have physicians, associate providers, nurses, and paramedics even broached the topic by examining the role of incorporating psychological skills into programs such as stress inoculation training.4,5

Performance Enhancing Psychological Skills (PEPS), can be used to mitigate the deleterious physiological and psychological responses in stressful situations and optimize delivery of emergency medical care. Although inherently similar to previously explored ‘mindfulness training’ and ‘metacognition,’ PEPS can be set apart as slightly more comprehensive skill-set. It encompasses a variety of techniques for regulating arousal and improving performance. It is based on a host of other evidence-based psychological skills used to train elite athletes, as well as successful business executives and special operations personnel in the military.

One such set of psychological skills, I propose, is called BTSF or “Beat the stress fool.” It stands for breath, talk, see, and focus. To these I would also add posture. In this and forthcoming posts I will review the elements of BTSF, discuss some the evidence behind them, and describe their potential application in the world of resuscitation.

Breathe: Using Performance Enhancing Breathing

The first element of PEPS, breathing, is the ability of the provider to learn to control and focus their attention on their breathing. Different breathing techniques have been used and developed over thousands of years to improve performance in various martial arts, meditative practices, and yoga.6 In fact, in ancient Japan samurai considered mastery of breathing techniques critical to performance in combat: “…breathing for the development of coordinated power-as is true in all major martial arts-is considered of the utmost importance…”7

Respiration is the only autonomic function that can be controlled and modified consciously. It can therefore be engaged as a means to control the effects of one’s emotional response. In fact, there is a close, bidirectional relationship between respiration and emotional state.8,9 The physiological result of employing a slow, deep, controlled respiratory effort is a reduction in heart rate, an important physiological manifestation of acute stress.10 Further evidence suggests that controlled breathing can increase one’s the emotional regulatory capability.11

An area of interest for many investigators is how to control the pathological features of post traumatic stress disorder (PTSD). This has been an area that has received increased attention following conflict overseas. Breathing, in addition to other therapeutic inventions, has demonstrated efficacy managing the symptoms of PTSD. In 2014, Seppala et al conducted a randomized controlled trial and demonstrated that breathing techniques can be used to decrease stress response, anxiety, and hyperarousal in combat veterans with PTSD.12

Breathing techniques have been an important tool used by psychologists to help elite athletes improve their performance.13 In the setting of sports performance, as in previous mentioned areas, these techniques have been used to reduce anxiety and control arousal. Furthermore, they are applied to help athletes focus, increase their sense of stability or “centeredness”, and relax.14 Usually, psychologists recommend deep breathing is employed during a break in play action; for example, before serving a tennis ball, just before a penalty kick in soccer, or while getting ready for a free throw in basketball.15

In the instance of instance of resuscitation the method I recommend to control the respiratory cycle is to utilize the four-second method. Breath in deeply for four seconds, engaging your diaphragm and attempting to pull the breath down into your abdomen. Hold the breath in for four seconds. Then, exhale slowly over the course of four seconds and hold out for two to four seconds. This specific method is used by psychologists to help military and law enforcement personnel manage their response during acutely stressful incidents. In these settings, it is often referred to as “Tactical Breathing.”16,17 Sometimes this technique is simply referred to this as “box” or “square” breathing. In other realms, psychologists have referred to it as “Performance Enhancing Breathing.”18

If you want to conquer the anxiety of life, live in the moment, live in the breath. -Amit Ray

Thanks Mike. Neat mnemonic to remember the 4 basic skills + power pose a la Amy Cuddy. I teach these skills to intensive care and ED trainees for work and exam preparation after learning that the SEALS use them. I’ve recently been experimenting with EMDR as there seems to be growing evidence to support its effectiveness. I think the 4 skills + power pose + EMDR form the basic psychological tools to fortify one’s psychological armour. Mark Divine’s material is very helpful.

Thanks for commenting. Yeah, Mark Divine’s stuff is really great. He is intelligent, insightful, and well-spoken. I am particularly fond of his book, “Unbeatable Mind.” I think we would do well to adapt some of his concepts to resuscitation.

Interesting that you mention the eye movement desensitization reprocessing (EMDR) approach. Most of what I have read seems to indicate that it enjoys similar results to cognitive behavioral therapy (CBT). Therefore, I have focused primarily on CBT in the form of stress exposure training. The performance enhancing psychological skills (PEPS) that I am discussing here are taught as part of the “skills acquisition phase” in the exposure training.

That said, this approach is really a product of my past experience and, perhaps, lack of familiarity with EMDR. I guess I have lacked the ingenuity necessary to develop it into a non-psychotherapeutic model for medical training. How do you apply or include the EMDR in your training or preparation of medical providers? I think this is fascinating and would love to hear more about it.

Thanks again for reading!

-Mike

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3 years ago

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Robin Choong

Hi Mike Thanks for your thoughts. Like you, I have mainly used CBT in stress exposure training. I’ve always had an interest in performance psychology and originally did a course in NLP in 1994. Though I found benefit in NLP, the academic rigor for NLP was a little disappointing and my focus moved towards CBT which has much better evidence supporting it. When I first read about EMDR a number of years ago, I thought it was a ‘fringe’ therapy and paid little further attention to it. However, more recently, my interest in EMDR was re-ignited after reading a news report of EMDR being used with First Responders to deal with PTSD and associated stress and anxiety. In Australia, there have been a number of Paramedics who have committed suicide as a result of unrecognised and/or inadequately managed PTSD. When I did a literature search, I was impressed with the growing body of knowledge supporting this therapy. The neurological basis of EMDR is thought to involve interactions between the ACC and limbic system. When I said that I was experimenting with EMDR, I think I may have misled you somewhat. My sample size thus far is one, i.e moi. So… Read more »

[…] provides a cognitive stop point in the management of a sick child – five seconds to get our breathing under control – before going forward. There is data to suggest that pressing for longer leads to a longer […]

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2 years ago

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Jay

Love these posts but you got to proof read bro! Last paragraph, “In the instance of instance of resuscitation..”
You’re a smart guy, don’t settle!